Case Your intern admitted a patient with pneumonia and symptoms of heroin withdrawal. She did a very cursory workup, and did not treat the patient’s withdrawal symptoms at all. When you question her, she says : “What’s the point? She is just going to leave AMA anyway. I don’t have time for this.” Is this a motivated intern??? Rich talked about MOTIVATION as not being a trait, an all or nothing, he talked about a state of ambivalence with patients “Assessing readiness to change” --- “Assessing readiness to learn”

You point out the importance of managing withdrawal symptoms in an acutely ill patient and offer to review the management of heroin withdrawal with her. Your intern rolls her eyes.

What is the diagnosis?

The Reluctant Learner Angela Jackson, MD Rachel Stark, MD, MPH Vice Chair for Education, Director, Primary Care Training Program and Rachel Stark, MD, MPH Asst. Director, Primary Care Training Program

Goals of the session: Define Reluctant Learner “Diagnose” the reluctant learner Discuss in small groups effective approaches to engage the reluctant learner

The Reluctant Learner Definition: A learner who appears not to be eager, willing and ready to learn what you want to teach Why is it that the reluctant learner elicits such a strong reaction from us? Investment in what we are doing, a strong sense of the “right thing to do” for the patient, a strong sense that what we are trying to teach matters, is important to patient care, etc

Examples of reluctant learners… (and why they are so memorable…) Brainstorm examples of reluctant learners- What do we call “reluctant learners?” “jerks” Losers uninterested

Examples of reluctant learners… The Know It All The Minimizer Passive-Aggressive The Lazy Learner Excuses, excuses… Not my job! Disinterested/Bored The Head Bobber

Why the reluctance? Brainstorm

Example of boring attending rounds as a student or resident Reluctance is not a permanent personality “trait”, but a modifiable “state” Example of boring attending rounds as a student or resident

Approach the reluctant learner as you would a “clinical case”

STEP 1- Make the Diagnosis: “Take a History” Remain neutral and objective, and TAKE A FULL HISTORY

Diagnose the Learner: Remember - ASK

Have a problem with Attitude? ASK - Does the learner: Have a problem with Attitude? - judgmental - “bleeding heart” who can’t set limits Lack Skill? - unable to put knowledge to practical use - uncomfortable asking the questions Lack Knowledge? - clinical relevance of material - missing some “background information” Knowledge- Does the learner not understand the clinical relevance of what you are trying to teach? Does the learner need some “background information”, before able to grasp a new teaching point. For example, if they don’t know that DT’s carries a significant mortality rate, they may not be very excited about learning how to prevent it. Diagnosis: Problem with attitude: Professional and Personal Psychiatric issues, substance use Cognitive problems Confidence Motivation

The Learning Process CONTEXT LEARNER TEACHER CONTENT

“Find the Lesion” for Educators: Example: Teacher Learner Content Appears not to be interested Too longwinded? Not clear on relevance to clinical setting? Post-call ? Just reviewed this with the CR? Distracted with-sick pt? Life? Clinical relevance not clear? Background knowledge missing? Know it All Intimidating? Or tentative? Does in fact, master this material? Afraid to admit deficiency? Too basic? Importance not made clear?

STEP 2 – Treat the Problem: “The Therapeutic Trial” It usually takes more than one try Keep the focus on the behavior Keep your goal realistic Therapeutic trials: It usually takes more than one try Be consistent and be fair Keep the focus on the behavior, not the individual Distinguish isolated episodes from patterns Keep notes

“The Therapeutic Trial” Treatment Options:

Principles of Motivational Interviewing (MI): Develop DISCREPANCY Avoid ARGUMENTATION Roll with RESISTANCE Express EMPATHY Support SELF-EFFICACY

Principles of Managing Interns: Develop DISCREPANCY Avoid ARGUMENTATION Roll with RESISTANCE Express EMPATHY Support SELF-EFFICACY Discrepancy- Few HOs are truly psychopaths Argumentation – Confrontation will cause the learner to feel attacked and resist suggestions Roll with resistance –rather than confrontation, “rolling” with the resistance means diffusing the resistance, getting the conversation to go in another direction, rather than shutting down Empathy – “seeing the world thru the learner’s eyes” , demonstration of an understanding of the learner’s expereince– does not mean agreeing with the behavior/position, etc Self-efficacy – “change is possible”- highlight past success, variety of options, they decide how to change

STEP 3 – Get a Consult: Other colleagues Program Director Clerkship Director

Diagnosis and Treatment Options: PROBLEM:____________________________________ Possible Dxs Possible Rxs:

“Stages of Change” for the Reluctant Learner “This is not important for good patient care” “I already know all I need to” Pre-contemplation “There may bean easier way to deal with this kind of problem, but I am doing fine” Contemplation Determination “There are some concrete skills that I can learn and use” “Mastering these skills will make me a better doctor”

RELAPSE “RECOVERY” Fatigue Burn out Personal issues Substance use “I understand the importance of this skill to good patient care I can do this” “RECOVERY” Fatigue Burn out Personal issues Substance use RELAPSE

Take Home Points: “Reluctance is in the eye of the beholder” The same systematic approach and the same skills that work with challenging patients, work with challenging (reluctant) learners